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Cardio Lecture 7
Management of Hypertension 1/28/13
59
Pharmacology
Graduate
01/31/2013

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Cards

Term
What qualifies someone as normal blood pressure?
Definition
<120/<80

Based on the average of 2 or more seated readings taken at each of 2 or more visits.
Term
What qualifies someone as prehypertension?
Definition
120-139 / 80-89

Based on the average of 2 or more seated readings taken at each of 2 or more visits.
Term
What qualifies someone as stage-1 hypertension?
Definition
140-159 / 90-99

Based on the average of 2 or more seated readings taken at each of 2 or more visits.
Term
What qualifies someone as stage-2 hypertension?
Definition
>160/>100

Based on the average of 2 or more seated readings taken at each of 2 or more visits.
Term
Define isolated systolic hypertension
Definition
Systolic blood pressure 140 mm Hg or greater and diastolic blood pressure less than 90 mm Hg and staged appropriately (e.g., 170/78 mm Hg is defined as stage 2 isolated systolic hypertension).
Term
What are the recommended follow up times based on blood pressure classification?
Definition
Normal- 2 years
Pre-hypertension- 1 year
Stage 1 HTN- 2 months
Stage 2 HTN- within 1 month or 1 week if >180/110
Term
List 9 Major risk factors for cardiovascular risk
Definition
1.Hypertension
2.Cigarette smoking
3.Obesity (body mass index 30 kg/m2)
4.Physical inactivity
5.Dyslipidemia
6.Diabetes mellitus
7.Microalbuminuria or estimated glomerular filtration rate <60 mL/min
8.Age (older than 55 for men, 65 for women)
9.Family history of premature CVD (men under age 55 or women under age 65)
Term
List 9 key pieces of information to be obtained during a medical history for HTN
Definition
1. Blood pressure levels
2. History of heart or metabolic problems
3. Family history
4. Symptoms of secondary causes of hypertension
5. History of weight, physical activity, and tobacco use
6. Diet assessment
7. History of all drug use
8. Results of previous HTN therapy
9. Patient environmental/social factors (stress)
Term
List three tests that must be obtained before initiating therapy of a hypertensive patient
Definition
1. Urinalysis (to assess target organ damage)
2. Blood chemistry (K, Na, Scr, glu, lipid profile)
3. Electrocardiogram- to assess for CVD and get baseline
Term
Define bradycardia
Definition
Heart rates below 60bpm

Beta blockers may be contraindicated
Term
What is the goal of hypertension management?
Definition
To reduce cardiovascular and renal morbidity and mortality.

The primary focus should be on achieving the systolic blood pressure goal
Term
What are the blood pressure goals for uncomplicated hypertension or diabetes?
Definition
<140/90
Term
What are the blood pressure goals for renal disease, diabetes with proteinuria, CAD, or high CAD risk?
Definition
<130/80
Term
What is the blood pressure goal for heart failure?
Definition
<120/80
Term
List 6 lifestyle modifications for HTN prevention and management
Definition
1. Weight reduction
2. DASH diet
3. Sodium restriction
4. Physical activity
5. Moderation of alcohol consumption (<2 drinks a day for men, <1 for women)
6. Stop smoking
Term
Describe a DASH (Dietary Approaches to Stop Hypertension) eating plan
Definition
A diet rich in fruits, vegetables, and low-fat dairy products with reduced content of saturated and total fat. Maintain adequate intake of dietary potassium, calcium, and magnesium.
Term
Under what conditions does AHA recommend beta blockers first line for hypertension?
Definition
AHA reports that BB should still be used first line for compelling indications (angina, post MI, heart failure), but not first line for uncomplicated HTN due to “weak” data for cardioprotection.
Term
What drug class is considered the best to prevent cardiovascular complications of HTN?
Definition
Thiazides
Term
What were the results of the ALLHAT (The Antihypertensive and Lipid Lowering to Prevent Heart Attack Trial)?
Definition
-Diuretics provide similar blood pressure lowering effects when compared to ACE inhibitor, CCB, or alpha blocker.
-All others more effective than alpha blockers at preventing heart failure
-Beta blockers were not tested
Term
Other than drug class, what does the JNC-7 recommend in starting HTN therapy?
Definition
-Start with lowest possible dose
-Use a once-daily agent
Term
What drug class does JNC-7 recommend in starting HTN therapy?

Assume there are no compelling indications or contraindications in the patient.
Definition
A thiazide-type diuretic either alone or in combination with an ACE-I, ARB, BB, or CCB

Most patients will need two or more medications, but wait a month to assess effect before adjusting
Term
What follow-up and monitoring recommendations are there once antihypertensive drug therapy is initiated?
Definition
-BP monitoring at monthly intervals until goal met
-Once BP at goal, 3-6 month intervals
-Potassium and Scr 1-2 a year until deemed stable
Term
What are common side effects of thiazide and loop diuretics?
Definition
1. Short term ↑ cholesterol, glucose
2. ↓ K, Na, Cl, Mg
3. ↑ Scr, uric acid, and Ca
Term
List the daily dosage of HCTZ and monitoring needed
Definition
daily dosing range: 12.5-50 mg (max effective dose is 25 mg)

dosing frequency: QD

monitoring: Chem-7 (sodium (Na+),
potassium (K+), chloride (Cl-), CO2, blood urea nitrogen (BUN), serum creatinine (SCr), and glucose), BP
Term
List the daily dosage of furosemide and monitoring needed
Definition
daily dosing range: 40-240 mg
dosing frequency: BID-TID
monitoring: Chem-7 (K+, SCr), BP
Term
List the daily dosage of triamterene (a K-sparing diuretic) and monitoring needed
Definition
daily dosing range: 25-100 mg
dosing frequency: QD
monitoring: Chem-7 (K+, SCr), BP
Term
List the daily dosage of spironolactone and monitoring needed
Definition
daily dosing range: 25-50 mg
dosing frequency: QD-BID
monitoring: Chem-7 (K+, SCr), BP, questions about adverse effects
Term
List the daily dosage of aliskiren (a renin inhibitor), adverse effects, and monitoring needed
Definition
daily dosing range: 150-300 mg

dosing frequency: QD

adverse effects: angioedema, hyperkalemia (especially in diabetes treated with ACE-I), diarrhea, GI upset, dizziness

monitoring: Chem-7 (K+, SCr), BP, questions about adverse effects
Term
List the daily dosage of reserpine (a peripheral adrenergic inhibitor), adverse effects, and monitoring needed
Definition
daily dosing range: 0.05-0.25 mg

dosing frequency: QD

adverse effects: nasal congestion, sedation (depression and activation of peptic ulcer disease – uncommon at the recommended dosing range)

monitoring: BP, questions about adverse effects
Term
List the daily dosage of clonidine (a central alpha-agonist), adverse effects, and monitoring needed
Definition
daily dosing range: 0.2-1.2 mg

dosing frequency: BID-TID

adverse effects: sedation, dry mouth, lethargy, bradycardia, withdrawal rebound hypertension, impaired cognitive functioning in elderly patients

monitoring: BP, EKG, questions about adverse effects
Term
List the daily dosage of doxazosin (an alpha blocker), adverse effects, and monitoring needed
Definition
daily dosing range: 1-16 mg

dosing frequency: QD

adverse effects: postural hypotension, especially after the first dose and in the elderly or diabetic patient due to impaired autonomic nervous system function

monitoring: BP (sitting and standing), questions about adverse effects
Term
List common side effects of beta-blockers
Definition
bradycardia
bronchospasm – use is contraindicated in asthmatics and other lung diseases
heart failure (systolic dysfunction)
may mask insulin-induced hypoglycemia and delay recovery time ( more pronounced with non-specific beta-blockers)
impaired peripheral circulation – hard to quantify
insomnia
fatigue
impaired cognitive functioning in elderly patients
decreased exercise tolerance
sexual dysfunction (erectile dysfunction, impotence)
Term
List the daily dosage of atenolol and monitoring needed
Definition
daily dosing range: 25-100 mg
dosing frequency: QD
monitoring: BP, HR, EKG, questions about adverse effects
Term
List the daily dosage of propanolol and monitoring needed
Definition
daily dosing range: 40-480 mg
dosing frequency: BID
monitoring: BP, HR, EKG, questions about adverse effects
Term
List the daily dosage of carvedilol and monitoring needed
Definition
daily dosing range: 12.5-50 mg
dosing frequency: BID
adverse effects: postural hypotension, same as beta-blockers and alpha-blockers
monitoring: BP, EKG, questions about adverse effects
Term
List the daily dosage of minoxidil (a direct vasodilator), side effects, and monitoring needed
Definition
daily dosing range: 5-100mg
dosing frequency: QD

adverse effects: orthostatis hypotension (especially in older patients), headaches, fluid retention, tachycardia, hirsutism

monitoring: BP, questions about adverse effects, physical assessment
Term
List the daily dosage of verapamil, side effects, and monitoring needed
Definition
daily dosing range: 90-480 mg
dosing freqency: QD-BID

adverse effects: impaired cardiac conduction, bradycardia, worsening of systolic function in heart failure, constipation

monitoring: BP, HR, EKG, questions about adverse effects
Term
List the daily dosage of diltiazem, side effects, and monitoring needed
Definition
daily dosing range: 120-360 mg
dosing frequency: QD-BID

adverse effects: impaired cardiac conduction, bradycardia, worsening of systolic function in heart failure

monitoring: BP, HR, EKG, questions about adverse effects
Term
List the daily dosage of amlodipine, side effects, and monitoring needed
Definition
daily dosing range: 2.5-10mg
dosing frequency: QD

adverse effects: ankle edema, flushing, headache

monitoring: BP, questions about adverse effects, physical assessment
Term
List the daily dosage of lisinopril, side effects, and monitoring needed
Definition
daily dosing range: 5-40 mg
dosing frequency: QD

adverse effects: cough (in up to 25-30%), hyperkalemia (especially in diabetics and those with renal insufficiency), elevated SCr, angioedema (rare, but life-threatening), rash, loss of taste

monitoring: Chem-7 (K+, SCr), BP, questions about adverse effects, physical assessment
Term
List the daily dosage of valsartan, side effects, and monitoring needed
Definition
daily dosing range: 80-320 mg
dosing frequency: QD

adverse effects: hyperkalemia

monitoring: Chem-7 (K+, SCr), BP
Term
What is the most common form of target organ damage associated with HTN?
Definition
IHD
Term
What is the therapy of choice in someone with stable angina and HTN?
Definition
First drug of choice is a BB; alternatively, long-acting CCBs can be used.

Short-acting calcium antagonists should not be used because of the risk for myocardial ischemia or myocardial infarction.
Term
What is the therapy of choice in someone with unstable angina/MI and HTN?
Definition
BB and ACE-I
Term
What is the recommended treatment for a patient with asymptomatic heart failure?
Definition
ACE-Is and BBs are recommended.
Term
What is the recommended treatment for a patient with symptomatic heart failure?
Definition
In those with symptomatic ventricular dysfunction or end-stage heart disease, ACE-I, BB, ARB, and aldosterone antagonists are recommended with loop diuretics.
Term
What is the recommended treatment for a diabetic with hypertension?
Definition
Thiazide diuretics, BB, ACE-I, ARB, and CCB, are beneficial in reducing CVD and stroke incidence in patients with diabetes
Term
What is the American Diabetes Association 2013 Clinical Practice Guidelines blood pressure goal?
Definition
<140/80
Term
Define chronic kidney disease
Definition
either reduced excretory function with an estimated glomerular filtration rate (GFR) below 60 ml/min OR the presence of albuminuria
Term
What is the drug treatment of choice for a patient with chronic kidney disease?
Definition
ACE-I and ARBs, but loop diuretics may be needed in combination with advanced renal disease
Term
What are the guidelines of treatment of HTN in a patient with a stroke?
Definition
-Reduce BP gradually
-Control at 160/100 is appropriate until condition is stabilized or improved
-Combination of ACE-I and thiazide
Term
What are treatment guidelines for African Americans with HTN?
Definition
-Lifestyle modifications especially
-Diuretics should be agents of first choice
Term
Define left ventricular hypertrophy as it relates to HTN
Definition
LVH is a risk factor for CVD

It can be managed with all classes except direct vasodilators
Term
How does HTN therapy change for elderly?
Definition
Generally it doesn't change, but be aware to titrate and watch for orthostatic hypotension or cognitive functioning
Term
How can thiazides and loop diuretics effect dyslipidemia?
Definition
In high doses, thiazide diuretics and loop diuretics can induce at least short-term increases in levels of total cholesterol, triglycerides, and LDL-cholesterol.

Low doses do not produce this
Term
How can BBs, alpha blockers, and other HTN drugs effect dyslipidemia?
Definition
Beta blockers may increase TG but reduce death anyway
Alpha-blockers can decrease cholesterol
All others are lipid neutral
Term
What HTN drugs should be avoided in an asthmatic?
Definition
Beta-blockers, alpha-beta-blockers, and topical ophthalmic application of beta-blockers
Term
How does gout affect HTN treatment?
Definition
Diuretics should be avoided if possible, since they can increase uric acid (but this rarely causes an acute gout attack)
Term
What are the preferred HTN drugs in pregnancy?
Definition
Methyldopa, BB, or vasodilators
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